Endo NP Forms

Sherwood Dental

501 Krug St #113
Kitchener, ON N2B 1L3
Phone: 519-576-2170

Today's Date*

Patient Name*

First Middle Last

Gender

Family Status*

Date of Birth*

Age*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone*

Email*

Work Phone

Extension Number

Health Card Number*

Family Physician*

First Last

Physician's Phone*

In Case of Emergency, We should notify:*

First Last

Relationship*

Phone*

Responsible Party Information Insurance Information

*Please note, patient is responsible with providing us a copy of their insurance card(s).*

Party responsible for payment*

Primary

Insurance Provider/Company Name

Group Number

Certificate Number

Name of Insured

First Last

Is Insured a patient?

Patient's relationship to insured

Insured's Birth Date

Age

Secondary

Insurance Provider/Company Name

Group Number

Certificate Number

Name of Insured

First Last

Is Insured a patient?

Patient's relationship to insured

Insured's Birth Date

Age

Allergies

List any medications and dosage (including Herbal):

1

2

3

4

5

6

7

8

9

Have you ever had any of the following? Please check those that apply:

Neural

Seizures/Epilepsy
Seizures/Epilepsy
Dizziness
Nervous/Mental Disorders
Stroke
Depression

Cardiovascular

Angina
Heart Attack
Bleeding Disorder
High/low Blood Pressure
Heart Disease
Pacemaker
Rheumatic fever
Heart Murmur

Pulmonary

Asthma / COPD
Difficulty breathing
Respiratory problems
Tuberculosis

Infectious

AIDS/ HIV
Hepatitis A B C
Venereal Disease

Immune

Hay fever
Allergy

Neoplastic

Cancer
Growths/Tumors
Radiation/Chemo

Digestive

Acid reflux Disease
Stomach Problems
Ulcers

Inflammatory

Arthritis
Rheumatism
Osteoporosis

Other

Diabetes
Artificial Joints
Glaucoma
Sinus Problems
Liver Disease
Kidney Disease
Sleep Apnea
Organ Transplant
Thyroid problems

Surgeries 1

Year

Surgeries 1

Year

Notes:

Have you ever had any complications following dental treatment?*

Have you been admitted to a hospital or needed emergency care during the past 2 years?*

For women only: Are you breastfeeding or is it possible that you are pregnant?*

Do you have any health problems that need further clarification?*

Do you smoke?*

Do you use recreational drugs?*

Do you have to take antibiotics every time prior to dental work or surgery?*

Do you take any medication that thins your blood or affects clotting/bruising?*

Have you or anyone related to you ever had problems with anesthetic?*

Consent*

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

Signature of patient, parent or guardian (Type in Your Name)*

Date*

* I understand that my family’s appointments are valuable, and that 2 Business days must be given if we are unable to attend appointments. A missed standard appointment may incur a fee.

*I will be required to pay for my family treatment at each visit.

*I understand that outstanding account balances may be passed to a Credit Agency and/or to the Ontario Court System.

*My dental insurance plan is a contract between myself and the organization providing me with the coverage. It is my responsibility to ensure that the treatment I request is covered. However, Sherwood Dental will help me to the best of their abilities to ensure accurate and timely completion of my insurance forms. Sherwood Dental has NO knowledge of what is covered by my insurance plan. If I have a booklet, Sherwood Dental will be able to interpret it for me. Many plans require Pre-Determinations to be forwarded for more extensive treatment. Sherwood Dental will complete these for me. To avoid any delays in receiving my payment from my insurance company I must send my claim immediately, if it is not submitted electronically.

* Sherwood Dental also understands that your time is valuable so we are intent on starting your appointment on time with the possible exception of short notice emergencies (which all of us might get and we would like to be seen as soon as possible)

* Sherwood Dental will always make every attempt to see emergency cases promptly.

* Sherwood Dental will accept Visa, MasterCard, debit or cash as method of payment.

* Sherwood Dental will propose my dental treatment with my long-term dental health in mind, and will do their best to give an accurate estimate.

Consent for Collection, Use and Disclosure of Personal Information

* I agree that Sherwood Dental has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. I can request to see a copy of the consent form and agree the personal information may be collected, used and disclosed as set out in the Privacy Policy of the Office which is in accordance with the Personal Health Information Protection Act, 2004.

Consent*

I have read the above conditions of treatment, payment and personal information and agree to their content.

Signature of patient, parent or guardian (Type in Your Name)*

Date*

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